Clinical Documentation Improvement Specialist

Optum; Florida; On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentives and recognition programs

Equity stock purchase plan

401(k) contribution

Job summary

Optum is seeking an experienced CDI Specialist to review inpatient records and improve documentation accuracy within 24–48 hours of admission. You will educate physicians, coordinate with HIM professionals, and develop CDI initiatives to support risk of mortality and severity of illness scoring.

This role requires 5+ years of acute care RN or CDI clinical background, strong clinical knowledge, and proficiency with EMR systems. Florida-based position with competitive benefits.

Qualifications

• Associate degree required; RN with CDI background preferred.
• 5+ years acute care RN or CDI experience.
• Advanced clinical knowledge in medicine, pathophysiology, and pharmacology.
• Strong communication with physicians.
• Proficient in Windows PC and EMR/EHR systems.

Responsibilities

• Review inpatient records within 24–48 hours of admission to ensure accurate coding.
• Follow up with providers to clarify documentation and improve specificity.
• Educate physicians on documentation requirements and CDI processes.
• Coordinate with HIM Coding Professionals and CDI teams.
• Lead CDI education strategies to improve documentation quality.
• Engage Care Coordination and Quality Management in improvement initiatives.

Skills

Acute care RN experience

CDI experience

Physician communication

EMR/EHR proficiency

Clinical pharmacology knowledge

Education

Associate's degree

BSN (preferred)

CCDS/CDIP/CCS certifications (preferred)

Tools

EMR software

MS Word

MS Excel

PowerPoint

Job description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.Join us to startCaring. Connecting. Growing together.

Primary Responsibilities:

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
• Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
• Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
• Provides face-to-face educational opportunities with physicians on a regular basis
• Provides complete follow through on all requests for clarification or recommendations for improvement
• Leads the development and execution of physician education strategies resulting in improved clinical documentation
• Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
• Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity
• Utilizes only the Optum360 approved clarification forms
• Proactively develops a reciprocal relationship with the HIM Coding Professionals
• Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
• Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
• Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Associate's degree
• 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology
• Advanced level of proficiency communicating & working closely with Physicians
• Intermediate level of proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records

Preferred Qualifications:

• BSN degree if a RN
• CCDS, CDIP or CCS certification
• 3+ years of CDI experience for an acute care hospital
• CAC experience (Computer Assistant Coding)

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Groupis a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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